Biomed Imaging Interv J 2006; 2(4):e58
doi: 10.2349/biij.2.4.e58
© 2006 Biomedical Imaging and
Intervention Journal
How I Do It
Shoulder ultrasound
SP Tan1, FRCR,
KJ Fairbairn*,2, FRCR,
JE Kirk1, MRCP,
WC Liong2, FRCR
1 Queens Medical Centre Campus, Nottingham
University Hospital, Nottingham, United Kingdom
2 City Hospital Campus, Nottingham University Hospital, Nottingham,
United Kingdom
INTRODUCTION
Shoulder ultrasound (US) can be done using various
techniques. It is useful to establish a standard technique to be familiar with
how normal structures appear. This will later assist in the recognition of
pathology.
Shoulder US can be confusing to the beginner. Shoulder
anatomy, as seen on real-time US, takes time to learn.
We demonstrate our standard technique for looking at rotator
cuff pathology. Much of it was taught by our teachers or learnt from standard
textbooks on musculoskeletal US.
First, we image the subscapularis (SUBSCAP), biceps (BT),
supraspinatus (SST) and infraspinatus (IST) tendons. We look for impingement of
the SST under the acromion process. We also image the acromioclavicular joint.
We do not routinely image the teres minor tendon.
We hope to teach the beginner by using videos that show how
each structure is scanned. US cine-loops show what is seen on the scanning
monitor. Frozen US images with labelled line drawings are given to explain the
structures seen.
This article is not comprehensive and includes no examples
of pathology. We hope it will serve as a supplement to a standard textbook such
as the one referenced [1].
Instrument
We use a linear transducer – at least 7.5 MHz.
Technique
We routinely review radiographs of the shoulder of interest
if available.
The following bony points are used to aid in positioning of
the transducer (Movie 1):
●
C – Lateral end of clavicle
●
A – Acromion process
●
Co – Coracoid process (not easily palpable but easily located by US as
the bony projection inferior to the lateral third of the clavicle)
Subscapularis tendon (SUBSCAP)
●
Patient sits on the examination couch facing the examiner. The patient’s
arm is at his side and his elbow flexed. His forearm is supinated (Figure 1).
●
The probe is placed axially at about the level of the coracoid process.
You will see a longitudinal view of the SUBSCAP. The patient is asked to
externally rotate his shoulder while keeping his arm by his side for a dynamic
view of this muscle and tendon (Movie 2).
Cine-loop 1 shows the SUBSCAP in dynamic movement. Figures 2
and 3 are the frozen US image and the labelled line drawing respectively
depicting a longitudinal view of the SUBSCAP in the neutral position and in
external rotation.
Biceps tendon (BT)
●
The patient is positioned as explained above for for SUBSCAP.
●
The probe is placed axially at the anterior aspect of the shoulder at
the level of the coracoid process slightly more lateral than for the SUBSCAP.
You will see a transverse view of the BT in the bicipital groove. Pan up and
down to follow the visible length of the BT. The probe is then positioned
sagittally for a longitudinal view. Pan medial to lateral. You may need to tilt
or ‘heel or toe’ the transducer to see the normal fibrillary pattern of the
tendon. (Movie 3)
Cine-loop 2 shows the biceps tendon in transverse and in
longitudinal views. Figures 4 and 5 are the frozen US image and the labelled
line drawing respectively, depicting a transverse view of the BT. Figures 6 and
7 are the frozen US image and the labelled line diagram of a longitudinal view
of this tendon.
Supraspinatus (SST) and infraspinatus (IST) tendons.
These two tendons are positioned superior to the
glenohumeral joint. They lie inferior to the acromion process. The SST is
anterior and the IST is posterior. It is difficult to clearly separate these
two tendons on US.
●
The patient is asked to rest the back of his hand on the couch behind
him (waiter’s tip position) (Figure 8).
●
Place probe in the sagittal oblique position just superior to the coracoid
process. You will get a transverse view of the proximal SST with the
anterior-most aspect of the SST marked by the BT. Pan posteriorly for the IST.
Follow these tendons inferolaterally to see their insertion into the greater
tuberosity of the humerus. Place probe in the coronal oblique position to get a
longitudinal view of these tendons. Pan anteriorly for the SST and posteriorly
for the IST. (Movie 4)
Cine-loop 3 shows the SST and IST in transverse and
longitudinal views. Figures 9 and 10 are the frozen US image and the labelled
line diagram respectively depicting a transverse view of the proximal SST and
IST. Figures 11 and 12 are the frozen US image and the labelled line drawing
respectively depicting a transverse view of the distal SST and IST. Figures 13
and 14 are the frozen US image and the labelled line drawing respectively
depicting a longitudinal view of these two tendons.
Impingement
●
Patient’s position as for examination of the SST and IST.
●
Place probe in the coronal oblique position at the acromion process. You
will see the SST in its longitudinal view lying just below the acromion
process. Observe the smooth gliding of this tendon under the acromion process
as the patient abducts his shoulder. (Movie 5)
Cine-loop 4 shows the SST gliding under the acromion
process. The starting position is with the shoulder in internal rotation (IR)
and adduction followed by shoulder abduction (ABD). Figures 15 and 16 are the
frozen US images and the labelled line drawing respectively depicting a
longitudinal view of the SST with the shoulder in internal rotation (IR) and
adduction; and followed by shoulder abduction (ABD).
Acromioclavicular joint (ACJ)
●
Patient’s position as for examination of the SUBSCAP. Place probe in the
coronal oblique position at the acromion process. Move probe slightly medially
to visualise ACJ (Figure 17). Note width of gap.
●
Ask the patient to move his arm across his chest so that his hand
touches his opposite shoulder (Figure 18). Notice narrowing of the ACJ space
(Scarf Test) (Movie 6). A positive test is when the patient feels pain at the
ACJ with this manoeuvre.
Cine-loop 5 shows the ACJ as the patient does the Scarf
test. Figures 19 and 20 show the frozen US image and the labelled line drawing
respectively of the ACJ in the resting position and on doing the Scarf test.
REFERENCES
-
van Holsbeeck MT, Introcaso JH. Musculoskeletal Ultrasound. St. Louis, Missouri: Mosby Inc.
Received 26 May 2006; received in revised form 7 November 2006; accepted 30 December 2006
Correspondence: Imaging Department, City Hospital Campus, Nottingham University Hospitals, Hucknall Road, Nottingham, NG5 1PB, United Kingdom. E-mail: kjuliafairbairn@aol.com (KJ Fairbairn).
Please cite as: Tan SP, Fairbairn KJ, Kirk JE, Liong WC,
Shoulder ultrasound, Biomed Imaging Interv J 2006; 2(4):e58
<URL: http://www.biij.org/2006/4/e58/>
This article has been viewed 4244 times.
|
|
Leave a comment